Infant Feeding and Institutional Adherence with the Baby-Friendly Initiative: An Assessment through Maternal Experience and Review of Policy and Protocol

(1)

Infant Feeding and Institutional Adherence with the Baby-Friendly Initiative:

An Assessment through Maternal Experience and Review of Policy and Protocol

Laura M. Fullerton, BA (Hons), MSc (Med) Diana L. Gustafson, BA, MEd, PhD

Report for the Newfoundland and Labrador Provincial Perinatal Program and Baby-Friendly Council of Newfoundland and Labrador

Division of Community Health and Humanities Faculty of Medicine

Memorial University

St. John’s, Newfoundland and Labrador February 2015

(2)

Executive Summary

The World Health Organization and the United Nations International Children’s Emergency Fund recommend exclusive breastfeeding for the first six months of life for optimal infant health and development. Exclusive breastfeeding means feeding an infant with breastmilk and no other liquids, foods, or breastmilk substitutes. Previous research indicates that the benefits of

breastfeeding extend beyond infancy and childhood to influence health outcomes throughout the life course. The rates of exclusive breastfeeding in Newfoundland and Labrador for the

recommended six-month duration are significantly lower than the national average at 5.8% and 14.4% respectively (Chalmers et al., 2009).

The Baby-Friendly Hospital Initiative (BFHI) is a global health promotion initiative committed to improving maternal-infant health by improving rates of exclusive breastfeeding. The initiative and its Ten Steps to Successful Breastfeeding provide guidelines to hospitals and birthing

facilities for implementing evidence-informed standards for patient care in pregnancy, childbirth, and the early post-partum period with a goal of improving breastfeeding initiation, duration, and exclusivity.

The purpose of this research was to examine hospital adherence with infant feeding guidelines at the Janeway Children’s Hospital/Health Sciences Centre in St. John’s, NL. This interpretative phenomenological study conducted in 2012 included a systematic review of hospital infant feeding policies and protocols and an exploration of maternal healthcare and infant feeding experiences generated from individual and focus group interviews. The study revealed

discrepancies between BFI practice guidelines and hospital infant feeding healthcare practices, specifically a lack of full adherence with Steps 3-9 of the BFI, and inconclusive evidence about adherence with Step 10.

These findings reveal opportunities for improving breastfeeding initiation, duration and exclusivity. Nine key recommendations are to:

1. Update existing policies: Update Eastern Health infant feeding policies for healthy newborns to align with all Steps and Sub-Steps of the BFI Ten Steps to Successful Breastfeeding.

2. Prioritize regular policy communication among allied health professionals: Ensure health professionals working with mothers in pregnancy, labour/delivery, and post- partum recovery are knowledgeable of hospital policies about breastfeeding.

3. Provide regular and mandatory BFI training for health professionals: Ensure all health professionals providing care to mothers in pregnancy, labour/delivery, and the early post-partum period have completed BFI training, and have the knowledge and skills needed to confidently support the success of mother/infant dyads with breastfeeding.

4. Provide allied health professionals with the organizational and supportive work conditions necessary to implement BFI practice guidelines: Ensure all health

(3)

professionals working with mothers in pregnancy, labour/delivery, and the early post- partum period are supported (through, for example, appropriate scheduling, patient loads, length of shifts, access to resources) to provide mothers with high-quality and consistent infant feeding information, assistance, and support.

5. Enhance communication between mothers and allied health professionals: Ensure every mother has an opportunity, prior to discharge, to talk with a BFI-trained health professional about the importance and process of breastfeeding, and implications of supplementation, as well as how to recognize infant feeding cues, and signs of effective feeding. Ensure mothers are provided with regular opportunities during their hospital stay to talk with health care providers and ask questions.

6. Prioritize skin-to-skin contact for one full hour or as long as the mother wishes:

Ensure skin-to-skin contact immediately after birth for the duration of one hour or as long as the mother wishes.

7. Encourage overnight rooming-in the first night in hospital for all mother-infant dyads: Ensure mothers and infants remain together in the same room overnight. Do not separate mother/infant dyads overnight unless required for medical reasons.

8. Encourage cue-based feeding rather than feeding at timed intervals: Encourage mothers to feed on demand by recognizing and responding to infant feeding cues. Ensure mothers are aware of signs of effective feeding.

9. Provide mothers with access to a certified lactation consultant in hospital: Ensure a certified lactation consultant is available to assist mothers with breastfeeding in hospital 7 days a week.

(4)

Acknowledgements

This research was funded by the Canadian Institute for Health Research Priority Program (CIHR-RPP), the Research and Development Corporation of Newfoundland and Labrador (RDC), and Memorial University of Newfoundland (MUN).

We would like to thank the following for their support:

• Dr. Christopher Kaposy, Dr. Shree Mulay, Dr. Anne Drover, Janet Murphy-Goodridge, and Lorraine Burrage;

• The NL Provincial Perinatal Program and Baby-Friendly Council of NL; and

• All mothers who participated in this research.

Content for this report was drawn from the following thesis:

Fullerton, L.M. (2014). THESIS: Infant feeding and institutional compliance with the WHO/UNICEF Baby-Friendly Initiative – An assessment through maternal experience.

Memorial University.

For more information on this report, please contact:

Laura M. Fullerton

Division of Community Health and Humanities Faculty of Medicine

Memorial University, St. John’s, NL, A1B 3V6 Email: fullerton.laura@gmail.com

(5)

Background

The nutritional, immunological, and social benefits of breastfeeding are well evidenced and promoted through World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) guidelines for infant feeding practices. The WHO and UNICEF recommend exclusive breastfeeding for the first six months of life for optimal infant health and development. Exclusive breastfeeding means feeding an infant with breastmilk and no other liquids, foods, or breastmilk substitutes. Despite these recommendations, rates of exclusive breastfeeding in Newfoundland and Labrador (NL) for the recommended six-month duration are the lowest in Canada (Chalmers et al., 2009).

While many factors contribute to infant feeding practice, healthcare practices in the first minutes, hours, and days following birth have been shown to have a significant impact on breastfeeding rates of initiation, duration, and exclusivity (Kramer et al., 2001). Recognizing this, the WHO and UNICEF developed the Baby-Friendly Hospital Initiative (BFHI) to promote and support optimal infant feeding practices in healthcare settings. To achieve Baby-Friendly status, hospitals and birthing centers must follow best practices for infant feeding outlined in the WHO/UNICEF Ten Steps to Successful Breastfeeding guidelines. Although there are approximately 40

designated Baby-Friendly facilities in Canada, there are none located in the province of NL, highlighting an important opportunity to effect positive change in this province.

Breastfeeding – Why is it important?

The health benefits of breastfeeding are thoroughly examined in two systematic reviews and meta-analyses – one from the United States Agency for Healthcare Research and Quality (AHRQ) – Breastfeeding and maternal and infant health outcomes in developed countries, and the other from the WHO – Evidence on the long-term effects of breastfeeding. Both guiding documents analyze outcomes from hundreds of infant feeding studies to provide current data on the positive health outcomes of breastfeeding. While the AHRQ publication focuses on all potential short and long-term effects of breastfeeding for mothers and infants in high-income countries, the WHO publication is limited to the long-term impact of breastfeeding on adult disease outcomes for those who were breastfed in infancy.

The United States AHRQ reviewed approximately 400 systematic reviews, meta-analyses, randomized control trials, prospective cohort studies, and case-control studies appearing in MEDLINE, CINAHL and the Cochrane Library. The results of their multivariate statistical analysis indicated a statistically significant relationship between breastfeeding and reduced risk for acute otitis media, atopic dermatitis, asthma, childhood leukemia, necrotizing enterocolitis, obesity, severe lower respiratory tract infections, sudden infant death syndrome (SIDS), and type-1 and type-2 diabetes in infants and young children (Ip et al., 2007). Notably, there was no significant relationship found between breastfeeding and improved child cognitive development.

For mothers, benefits of breastfeeding included a reduced risk of breast cancer, ovarian cancer, type-2 diabetes, and post-partum depression.

The WHO systematic review and meta-analysis assessed the long-term impact of breastfeeding on adult blood pressure, cholesterol, overweight/obesity, type-2 diabetes, and cognitive

(7)

development. Observational and randomized studies were drawn from MEDLINE and the Scientific Citation Index. Results indicated a statistically significant relationship between breastfeeding and lower rates of blood pressure, cholesterol, overweight/obesity and type-2 diabetes, as well as between breastfeeding and higher cognitive development for those who breastfed in infancy versus those who had not (WHO, 2007). This review suggests that benefits of breastfeeding extend beyond infancy and childhood to influence health outcomes throughout the life course.

Together these reports provide compelling evidence to support the multiple health benefits of breastfeeding for mothers, infants, and the broader population. Although the WHO review found a significant association between breastfeeding and cognitive development, blood pressure, and cholesterol while the AHRQ review did not, results of these reviews provide overwhelming evidence in support of breastfeeding as a beneficial practice with the potential to protect against illness and disease, and improve overall public and population health.

The WHO (2006) states, “Interventions to improve breastfeeding practices are cost-effective and rank among those with the highest cost-benefit ratio. The cost per child is low compared to that for curative interventions” (p. 3). As with other preventive health practices, breastfeeding has the potential to lower rates of illness and disease, reduce healthcare spending, and lower demands on the healthcare system through its protective effect against chronic diseases and conditions

(WHO, 2006).

Breastfeeding is promoted widely by the WHO and UNICEF, along with other organizations, associations, and health authorities at the international, national, and community level for the promotion of optimal maternal-infant health. In Canada, the Public Health Agency of Canada (PHAC), Canadian Pediatric Society, Dieticians of Canada, Breastfeeding Committee of Canada, and others recommend exclusive breastfeeding for the first six-months of life, with

complementary feeding for two years and beyond, for optimal infant and child growth and development.

What is the WHO/UNICEF Baby-‐Friendly Hospital Initiative (BFHI)?

The WHO/UNICEF BFHI is a global health promotion initiative committed to improving maternal-infant health by improving rates of exclusive breastfeeding. Targeted toward hospitals and birthing facilities, the BFHI encourages healthcare institutions to implement evidence- informed standards for patient care in pregnancy, childbirth, and the early post-partum period.

BFHI guidelines are outlined in their Ten Steps to Successful Breastfeeding. Each step is

informed by evidence and designed to improve breastfeeding initiation, duration, and exclusivity.

By promoting best practices within hospital settings, the BFHI works to ensure mothers receive the instruction, assistance, information, and support they need to successfully breastfeed in hospital and upon discharge. In their joint statement on breastfeeding the WHO and UNICEF (1989) acknowledge the critical role of health care delivery in the establishment of breastfeeding success:

(8)

Of the many factors that affect the normal initiation and establishment of

breastfeeding, health care practices, particularly those related to the care of mothers and newborn infants, stand out as one of the most promising means of increasing the prevalence and duration of breastfeeding. (p. 4)

Since the initiative was launched in 1991, it has grown to include more than 20,000 designated Baby-Friendly facilities in 156 countries around the world (UNICEF/WHO, 2009). Any hospital or birthing facility can achieve Baby-Friendly status if it can demonstrate compliance with each of the Ten Steps to Successful Breastfeeding and with the International Code of Marketing of Breast-milk Substitutes. In 2009, the WHO and UNICEF updated the BFHI to incorporate current evidence on infant feeding.

Although the WHO and UNICEF are the global authority for the BFHI, when appropriate, organizations can be appointed by the WHO/UNICEF to oversee BFHI implementation at a national level (UNICEF/WHO, 2009). National authorities are responsible for overseeing the implementation and designation of the BFHI and International Code for Marketing of Breast- milk Substitutes, monitoring and evaluating infant feeding programs, activities and outcomes, and developing national infant feeding plans and activities (UNICEF/WHO, 2009).

The Breastfeeding Committee for Canada is the national authority for the BFHI in Canada, which is referred to as the Baby-Friendly Initiative (BFI). The Breastfeeding Committee for Canada made this title modification to better “reflect the continuum of care” in Canada by acknowledging that baby-friendly healthcare practices extend beyond hospital environments to include birthing centers, community services, and supports post-partum (BCC, 2012a). The Breastfeeding Committee for Canada adapted each step of the international WHO/UNICEF Ten Steps to better reflect the Canadian context by providing guidelines for both hospitals and community health services (BCC, 2012a). See Table 1.

Infant Feeding Practices in Canada and NL

Rates of exclusive breastfeeding for the optimal six-month duration in Canada fall much below WHO and UNICEF recommendations (Chalmers et al., 2009; PHAC, 2009). A nationwide study found that 90.3% of women in Canada initiated breastfeeding in 2006, but only 14.4%

exclusively breastfed for the recommended 6-month duration (Chalmers et al., 2009; PHAC, 2009). While national rates of exclusive breastfeeding are sub-optimal (especially for the 6- month recommended duration), rates of initiation and exclusive feeding in NL are among the lowest in Canada with 74.6% of mothers initiating breastfeeding (PHAC, 2009) and only 5.8%

exclusively breastfeeding for 6-months (Chalmers et al., 2009).

(9)

Table 1: BFI Integrated 10 Steps and WHO Code Practice Outcome Indicators

Integrated 10 Steps & WHO Code Practice Outcome Indicators for Hospitals and Community Health Services:

Summary

The WHO 10 Steps to Successful Breastfeeding (1989) and the Interpretation for Canadian Practice (2011)

WHO Have a written breastfeeding policy that is routinely communicated to all health care staff.

Step 1

Canada

Have a written breastfeeding policy that is routinely communicated to all health care providers and volunteers.

WHO Train all health care staff in the skills necessary to implement the policy.

Step 2

Canada

Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy.

WHO

Inform pregnant women and their families about the benefits and management of breastfeeding.

Step 3

Canada

Inform pregnant women and their families about the importance and process of breastfeeding.

WHO

Help mothers initiate breastfeeding within a half-‐hour of birth. WHO 2009: Place babies in skin-‐to-‐skin contact with their mothers immediately following birth for at least an hour.

Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.

Step 4

Canada

Place babies in uninterrupted skin-‐to-‐skin¹ contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes: encourage mothers to recognize when their babies are ready to feed, offering help as needed.

WHO

Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.

Step 5

Canada

Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants.

WHO Give newborns no food or drink other than breastmilk, unless medically indicated.

Step 6

Canada

Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated.

WHO Practice rooming-‐in – allow mothers and infants to remain together 24 hours a day.

Step 7

Canada

Facilitate 24-‐hour rooming-‐in for all mother-‐infant dyads: mothers and infants remain together.

WHO Encourage breastfeeding on demand.

Step 8

Canada

Encourage baby-‐led or cue-‐based breastfeeding.

Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.

WHO

Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

Step 9

Canada

Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).

WHO

Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Step 10

Canada

Provide a seamless transition between the services provided by the hospital, community health services and peer support programs.

Apply principles of Primary Health Care and Population Health to support the continuum of care and implement strategies that affect the broad determinants that will improve

1 The phrase “skin-‐to-‐skin care” is used for term infants while the phrase “kangaroo care” is preferred when addressing skin-‐to-‐skin care with premature babies.

(10)

breastfeeding outcomes.

WHO Compliance with the International Code of Marketing of Breastmilk Substitutes.

The

Code Canada Compliance with the International Code of Marketing of Breastmilk Substitutes.

(BCC, 2012b).

The NL Provincial Perinatal Program reported similar, albeit lower, rates of breastfeeding initiation in the province. Provincial Perinatal Surveillance System (2013) data reported a breastfeeding initiation rate² of 68.0% in 2012. Despite low rates of initiation, provincial data suggest steadily increasing rates of initiation in NL over the past two decades: “In 1986 the [breastfeeding initiation] rate was 35.3%, ten years later 56.3%, and in 2005, 63.6% with regional variations from a high of 70.7% in the Grenfell region, to a low of 44.5% in the rural Avalon region” (NL Provincial Perinatal Program, 2006).

Although trends reflect a positive change in provincial breastfeeding practice, they demonstrate significant regional variations, and opportunity for improvement. The potential for breastfeeding to promote health and protect against chronic conditions and disease in infancy and adulthood make it an important and cost effective practice worthy of promotion within the provincial healthcare sector and beyond.

2 NL Provincial Perinatal Program initiation rates are taken 48 hours after birth during neonatal screening and therefore better represent breastfeeding rates upon discharge than breastfeeding initiation.

(11)

Research Purpose and Objectives

The purpose of this interpretive phenomenological study was to examine hospital adherence with Steps 3-10³ of infant feeding guidelines outlined in the WHO/UNICEF Baby-Friendly Initiative (BFI) through an exploration of maternal healthcare and infant feeding experiences at the Janeway Children’s Hospital/Health Sciences Centre in St. John’s, NL in 2012.

The objectives of this research were to:

1. Provide detailed information on hospital infant feeding practices at the Janeway Children’s Hospital/Health Sciences Centre

2. Assess compliance with Steps 3-10 of the BFI Ten Steps to Successful Breastfeeding through an exploration of maternal hospital infant feeding experiences (reported maternal experiences were used as an indicator of hospital compliance)

3. Review infant feeding documents (policies and protocols) from the Janeway Children’s Hospital/Health Sciences Centre and compare them to international documents for infant feeding

4. Provide the Janeway Children’s Hospital/Health Sciences Centre, Eastern Health Authority, NL Provincial Perinatal Program, and Baby-Friendly Council of NL with a detailed assessment of hospital adherence with Steps 3-10 of the BFI Ten Steps to Successful Breastfeeding

5. Provide the Janeway Children’s Hospital/Health Sciences Centre, Eastern Health Authority, NL Provincial Perinatal Program, and Baby-Friendly Council of NL with recommendations that can be used to inform infant feeding programming, advocacy, and policy recommendations for the improvement of institutional adherence with BFI

guidelines

Twelve semi-structured one-to-one interviews were conducted with mothers one to four weeks following delivery. Interview participants were recruited through a pediatrician during her routine pre-discharge rounds in the Janeway Children’s Hospital/Health Sciences Centre Maternity Unit in March and April of 2012. Interviews ran from 20-75 minutes in length and were audio recorded with the permission of the participant. Research questions were designed to assess hospital adherence with Step 3-10 of the BFI, and the health care experiences of mothers.

The research sample included first, second and third time mothers, mothers with vaginal

deliveries and caesarian section deliveries, mothers ranging in age from their early 20’s to early 40’s, mothers who were married, unmarried, in a committed relationship and single, mothers who were exclusively breastfeeding, exclusively formula feeding, and combination feeding, and mothers living in rural and urban areas.

3 Adherence to Steps 1 and 2 were not assessed in this research, as the routine communication of hospital policies to hospital staff (Step 1), and the training of health care staff with necessary skills to implement BFI policy (Step 2) were expected to be outside the knowledge spectrum of mothers.

(12)

Three focus group discussions were held with groups of four to six mothers who gave birth at the Janeway Children’s Hospital/Health Sciences Centre from May 1^st, 2011 – May 1^st, 2012. All participants were recruited through word of mouth and snowball sampling. Each discussion was 60-90 minutes in length, audio recorded, and moderated by the principal investigator. As with individual interviews, focus group discussion questions were designed to assess hospital adherence with Step 3-10 of the BFI, and the health care experiences of mothers. The women who participated in the focus groups were very similar to those in the interview sample in terms of marital status, living arrangements, and number of children although they were a bit younger ranging in age from their early 20’s to late 30’s. These groups were made of up women who were exclusively breastfeeding and combination feeding with none of the mothers exclusively formula feeding.

Hospital infant-feeding policies used to guide clinical practice for healthy full-term infants at the Janeway Children’s Hospital/Health Sciences Centre were reviewed and compared to BFI guidelines. Policies were received in April 2012 from a lactation consultant and program coordinator of the NL Provincial Perinatal Program at the Janeway Children’s Hospital/Health Sciences Centre. Updated versions were received from the same lactation consultant and program coordinator in June 2013. All updated/re-issued policies detailed the same clinical guidelines and procedures as their earlier versions. Discrepancies between hospital policies and BFI guidelines are highlighted and recommendations for policy improvement are provided in this report.

(13)

Findings

Maternal healthcare experiences at the Janeway Children’s Hospital/Health Sciences Centre reveal a lack of complete adherence with optimal care practices outlined in the Steps 3-10 of the BFI Integrated Ten Steps. While accounts suggest that some healthcare practices are more closely aligned with guidelines than others, gaps are evident, and highlight areas for

improvement with infant feeding healthcare provision. In total, 27 mothers participated in this study: 12 interview participants and 15 focus group participants. Results on Steps 3-10 are summarized.⁴

Step 3 – Inform pregnant women and their families about the importance and process of breastfeeding

Step 3 involves speaking with pregnant women of 32 weeks or more gestation who attended two or more prenatal appointments to assess the quality of prenatal information on breastfeeding received. This research engages only with maternal experiences in hospital from the time of delivery until discharge. Therefore, the assessment of adherence with this step was limited to information mothers received in hospital using four indicators to explore the degree to which mothers were informed of the “importance and process of breastfeeding” (Table 2).

Table 2: Step 3 Interview Data

Yes No

Asked about infant feeding plans 8 4

Discussed infant feeding with healthcare provider 7 5

Breastfeeding recommended by healthcare provider 6 6

Pamphlets provided on importance and management of BF 12 0

When asked if nurses or physicians talked about the benefits and management of breastfeeding one participant said:

“I think the first time someone was like, ‘Okay, I’ll just turn his head like this and hold him like this.’ But no one talked to me about breastfeeding, except for [feeding every 3 hours. But no one actively talked to me about it.” (P8)

Similarly, focus group participants shared:

“There were lots of signs around, like I noticed there were a lot of signs saying,

“breastfeed.” (P25)

“Yeah, but nobody actually said [to do so].” (P22)

4 Number counts are only provided from one-to-one interviews (n=12) with mothers one to four weeks post-partum to limit recall bias and reflect hospital care experience from the narrow time frame of May 15^th, 2012 to April 5^th, 2012. Quotes are drawn from both interview participants (n=12) and focus group participants (n=15).

(14)

Results indicate a lack of routine and consistent verbal communication about breastfeeding in hospital, highlighting room for improvement with in-hospital communication and breastfeeding promotion.

Step 4 – Place babies in uninterrupted skin-‐to-‐skin contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes: Encourage mothers to recognize when their babies are ready to feed, offering help if needed.

Maternal accounts indicated that skin-to-skin contact immediately following delivery was widely practiced at the Janeway Children’s Hospital/Health Sciences Centre for both vaginal and

caesarean section deliveries, however often occurred for a shorter duration than recommended (Table 3).

While skin-to-skin contact was widely reported by mothers in this research, maternal accounts highlight that the duration and quality of skin-to-skin varied considerably from mother to mother.

Vaginal delivery

(n=7) C-‐section delivery (n=5)

Skin-‐to-‐skin provided:

Yes 6 5

No 1 0

Infant held by mother for the first time:

0-‐5 min after delivery 4 1

Duration of skin-‐to-‐skin contact

(of those (n=11) who received skin-‐to-‐skin):

0-‐5 min 2 0

6-‐10 min 0 0

11-‐20 min 1 3

21-‐30 min 2 0

31-‐60 min 0 1

61-‐90 min 1 1

Initiation of breastfeeding in hospital:

Yes 6 5

No 1 0

Initiation of breastfeeding during skin-‐to-‐skin

(of those (n=11) who received skin-‐to-‐skin):

Yes 5 5

No 1 0

(15)

One mother said:

“They asked me before I delivered if I wanted him on my chest… I got to hold him right away, and I held him for about an hour and a half, and just kind of sat there and I fed him right away.” (P4)

By contrast, another mother said:

“They brought her over for skin-to-skin, and I might have only got, say 10 minutes, and they [nurse] said, ’Okay, we've got to check her temperature now.’

And I said, ‘okay’ and I thought they were just gonna check and bring her back, but when they brought her back she was fully dressed… I didn't get the

opportunity. And I said, ‘I thought I was supposed to get a full hour of skin-to- skin’ and they said, ‘Well yeah, but you don't really need that. It's not necessary.’

And so I was kind of disappointed.” (P21)

Results indicate that uninterrupted skin-to-skin contact was often not practiced for the full- recommended duration of one hour and was not routinely offered to all. This indicates a shortcoming in the achievement of Step 4.

Step 5 – Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infant

Step 5 of the BFI includes the provision of initial and ongoing breastfeeding assistance and observation in hospital, but also instruction on how to hand express milk, how to recognize feeding cues,⁵ how to determine if the infant is effectively breastfeeding, and where to access breastfeeding help if needed.⁶ Although almost all breastfeeding mothers reported receiving assistance for their first feeding, some reported receiving no subsequent breastfeeding assistance/observation or offer of assistance/observation while in hospital (Table 4).

Yes No N/A*

Breastfeeding assistance offered or provided for first breastfeeding 11 1 0 Breastfeeding assistance offered/provided at subsequent intervals or as needed 8 3 1 Instructed or told how to initiate and maintain lactation if separated from infant 0 11 1

Pumping and breast-‐milk storage discussed 2 9 1

Instructed or told how to recognize infant feeding cues 4 8 0

Instructed or told how to determine if infant is effectively breastfeeding 2 9 1 * Assistance with breastfeeding and maintaining lactation is not applicable for those exclusively formula feeding.

5 Instruction on recognizing cue-based feeding is a component of Step 5, but study results on cue-based feeding are consolidated under Step 8.

6 Resources provided to mothers to promote transition from hospital to the community are discussed under Step 10.

(16)

Some mothers reported very positive experiences with the quality and frequency of breastfeeding assistance and support received in hospital:

“They made sure I was latching her on properly and you know, if I had any questions or whatever, they were there to tell me, ‘yes, no, well whatever feels good for you’ or they would get a pillow for me. They were awesome. I’ve got to say, the nursing staff were awesome.” (P7)

Some reported less positive experiences:

“They would come in and just take your boob, and shove it in, and not stay and try.

They would just do it for you because they didn’t want to stay and teach you how to do it.” (P10)

Still others felt disinclined to ask for help:

“I asked for help once, and the response I got… I was like, ‘I’m not gonna ask again.

It was frustration… she was like, (impatient voice) ‘Well what do you want?’ And I was like, ‘I just want, you know, some help with him latching.’ And they’re like, (frustrated sigh), and I’m cowering. So I didn’t ring it again because I was like…

well you know? But he ate, and I knew he would, but if I was a first time mom, oh my gosh, I would have jumped out of the window.” (P8)

The majority reported receiving no guidance on initiating or maintaining lactation if separated from their infant, or on pumping and breast milk storage. While a few reported receiving information/instruction on how to recognize and respond to infant feeding cues, and how to determine if their infant was effectively breastfeeding, the majority indicated they were not informed of this in hospital.

Step 6 – Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated

Step 6 of the BFI focuses on supporting mothers to exclusively breastfeed for the first six months of life, unless supplementing is medically necessary. The BFI emphasizes that those who

supplement should either be fully informed of their decision (through the provision of

information on the importance of exclusive breastfeeding and implications of supplementation), or advised to supplement for medical reasons (BCC, 2012a). Data for Step 6 is focused on breastfeeding exclusivity in hospital from the time of birth to the time of hospital discharge. Data on the breastfeeding support available to participants up to 6 months and beyond were outside the scope of this study.

(17)

Yes No

Breastfeeding initiated in hospital 11 1

Exclusive breastfeeding in hospital 7 5

Exclusive formula feeding in hospital 1 11

Combination feeding in hospital 4 8*

Free formula samples provided in hospital 2 10

* Of these, seven were exclusively breastfeeding and one was exclusively formula feeding

While the majority of mothers reported initiating breastfeeding in hospital, a number began supplementing with formula in hospital before discharge. Maternal accounts indicate a lack of routine dialogue between healthcare providers and mothers who supplemented with formula about the importance of exclusive breastfeeding and implications of supplementation.

“I tried to breastfeed him. I breastfed him for the first couple of days and then I found it way too hard because I was so sore and I was so tired. So I just found bottle- feeding to be a lot easier then afterwards. They wanted breastfeeding but the nurse said it was okay if I found it easier to bottle feed, a lot of people did, especially if that was your first child and you didn’t know what to expect.” (P5)

“All they did was they just asked me if I was bottle feeding or breastfeeding, and I just said bottle feeding, so they said that it was fine.” (P2)

Although exclusive breastfeeding was encouraged as routine practice in hospital, reported cases of supplementation occurred for non-medical reasons, and with little or no discussion about the importance of exclusive breastfeeding and implications of feeding with formula. Results suggest insufficient adherence with the guidelines outlined in Step 6.

Step 7 – Facilitate 24-‐hour rooming-‐in for all mother-‐infant dyads: mothers and infants remain together

Step 7 recommends that mothers and infants remain together in hospital 24 hours a day, and that mothers are able to have a support person with them in hospital 24 hours a day if desired (BCC, 2012a). Maternal accounts indicate routine mother-infant separation for infant bathing,

examination, and the first night in hospital. Many mothers also noted that they were not able to have a support person remain with them for 24 hours a day (Table 6).

(18)

Yes No

Mother-‐infant separated first night in hospital 10 2

If separated overnight, infant brought in for breastfeeding 9 1*

24-‐hour rooming-‐in remainder of hospital stay (after 1^st night) 12 0

Support person able to stay in hospital 24-‐hours a day 5 7

* This infant was exclusively formula fed and was not brought to mother for feeding during the first night

The following statements demonstrate the routine practice of overnight separation between mother-infant dyads at the Janeway Children’s Hospital/Health Sciences Centre.

“Right after he was born, they took him and kept him. I was supposed to sleep but I couldn’t sleep. They had him in the room where they keep all the little babies… Six hours they had him. I [delivered] him at 2 o’clock, and they brought him to me at 8 o’clock in the morning. I was supposed to sleep, but I couldn’t because I didn’t know where he was.” (P2)

P21: “I was told on my way up, ‘We really recommend that you don’t room-in, that you put the baby in the nursery.’”

P19: “So you could sleep?”

P21: “Yup, they said, ‘They gotta get a bath anyway. We really recommend you don’t take her’ and I was like, ‘Are you serious?’ I was really disappointed but not ready to argue it I guess. So I couldn’t sleep. I mean like I was in a ward with two people who were in labour, so I wasn’t sleeping. And so at 4am when I knew I should be feeding, I buzzed and said, ‘Can you bring the baby in?’ and I said, ‘You can leave her here now.’ They really strongly encouraged her not to room in.”

P20: “Yeah, the first night he didn’t stay with me.”

P21: “But that first night, like not being given the option, I felt really… like knowing that it should be policy.”

P17: “You’re like, ‘this is my baby.’”

P21: “I know, and I’m like, ‘You’re taking her away?’”

P17: “It wasn’t an option for us.”

P21: “I mean, I suppose it could have been an option. I suppose I could have demanded it but I felt like it was strongly discouraged.”

Although most mothers reported rooming-in after the first night of separation, 24-hour rooming- in was not widely practiced during the first night in hospital, and was not practiced for the full duration of hospital stay or during routine infant care. Poor rooming-in practices during the first 24-hours and mothers’ inability to have a support person remain in hospital 24-hours a day highlight important shortcomings in the implementation of Step 7.

(19)

Step 8 – Encourage baby-‐led or cue-‐based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods

Step 8 involves ensuring that mothers are encouraged to practice cue-based feeding and feeding for an unrestricted frequency or duration. Mothers are to be informed of how to identify signs of effective breastfeeding,⁷ and how to recognize their infant is ready for solid foods at 6 months of age or beyond (BCC, 2012a). Step 8 also recommends that mothers report being given an

opportunity to discuss sustained breastfeeding with staff for the first 6 months following birth and beyond. Because interview data was collected from mothers within 4 weeks following delivery, data was not collected on sustained breastfeeding up to 6 months or the introduction of solid foods.

Results indicate that mothers who delivered at the Janeway Children’s Hospital/Health Sciences Centre were encouraged to feed according to a fixed schedule rather than according to infant feeding cues (Table 7).

Yes No

Aware of infant feeding cues and feeding on demand in hospital 6 6

Encouraged to feed every 2.5 to 3 hours 12 0

As one mother shared:

P24: “I had one nurse get upset with me because I was on-demand feeding her. I fed her the 2-hour break in between, and I the nurse happened to walk by and she looked and she said, ‘What are you doing?’ And I said, ‘I'm feeding her.’ And she said, ‘Well it's not time to feed her.’"

Another mother stated:

P7: “They said to me, ‘Feed her every 3 hours.’ And that was like… it’s law. It’s every 3 hours, especially where they’re trying to get your milk to come in. And they didn’t really say, they just kind of woke her and me up every 3 hours.”

I: “Did they give you any indication of how long you should feed, or how to know when feedings over?”

P7: “Um no. That’s something that was confusing to me. It’s like, anywhere you go, you ask ten different people, you get ten different answers. And they come and they ask, ‘How was her feeding? How long was it?’ Some people would say, ‘Well, 20 minutes is not very long.’ And sometimes she’d be there anywhere from 20 minutes to 45 minutes, and they’d say, ‘Well 45 minutes is kind of too long, but 20 is not long enough.’”

7 Data on the signs of effective breastfeeding are discussed under Step 5.

(20)

Mothers reported that they were not consistently encouraged or instructed to practice cue-based feeding, were not well informed of infant feeding cues, and were not consistently instructed to breastfeed with unspecified frequency or duration, suggesting poor adherence with Step 7 of the BFI.

Step 9 – Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).

Step 9 involves supporting mothers to feed and care for their babies without using artificial teats or pacifiers, and providing mothers with appropriate information on feeding and caring for their babies without using artificial teats (BCC, 2012a). It is recommended that when an infant is given a bottle or pacifier, the decision is either medically indicated, or an informed decision made by the mother.

Table 8:

Step 9 Interview Data

*All who supplemented with formula in hospital did so using a bottle with an artificial nipple attachment

Focus group participants discussed using a bottle with a nipple attachment in hospital because no other option was available.

P19: “At the breastfeeding clinic, they try to do everything to try to get you to avoid using a bottle.”

P18: “I wasn’t given an option [in hospital]… there was no other method.”

Although research results consistently demonstrate the absence of pacifier use in hospital (Table 9), they highlight a lack of full adherence to Step 9 due to the frequent use of artificial nipple attachments on bottles and evidence suggesting a lack of engagement with mothers about artificial nipple and pacifier use.

Step 10 – Provide a seamless transition between the services provided by the hospital, community health services and peer support programs. Apply principles of Primary Health Care and Population Health to support the continuum of care and implement strategies that affect the broad determinants that will improve breastfeeding outcomes

Step 10 recommends that mothers are provided with accessible support and resources to facilitate a smooth transition from the hospital to the community. This involves ensuring mothers are provided with a way to access breastfeeding support outside of office hours, have access to peer support programs, and live in a community that is supportive of breastfeeding (BCC, 2012a).

Yes No

Use of pacifiers in hospital 0 12

Supplementing with formula in hospital 5 7

Use of artificial teat when supplementing (bottle with nipple attachment) 5* 0

(21)

All mothers interviewed reported receiving information on how to access breastfeeding support programs and written information on breastfeeding, pumping, and post partum care, as well as a follow up call or visit from a public health nurse following hospital discharge (Table 9).

“They gave me a pamphlet on the breastfeeding support groups, which we’ve been to, and they gave me all the different ones and what days are which and the times on them and stuff, so they explained all that right before we were discharged… They told us which ones had the lactation consultants and which ones were more social, which ones just for the groups to go see a nurse. It was nice, we wouldn’t have known otherwise.” (P4).

Yes No

Referred to a community breastfeeding support group 12 0

Received written information on breastfeeding, pumping, and post partum care 12 0 Received information on how to access breastfeeding support outside of office

hours

unknown unknown

Received follow-‐up call or visit from public health nurse following hospital discharge 12 0

It is unknown whether mothers received information in hospital about accessing breastfeeding support outside of office hours once discharged, as this was not explicitly asked. Maternal reports suggest possible full adherence to Step 10 at the Janeway Children’s Hospital/Health Sciences.

(22)

Policy Review Outcomes

Eastern Health had four infant feeding policies to guide care provision for healthy newborns in hospital in 2012. Together, these guided hospital infant feeding practice within the Janeway Children’s Hospital/Health Sciences Centre.

1. Skin-to-Skin Contact Immediately Following Birth I [Policy: 270 (WH) II-D-83]

• Protocol for the administration/provision of skin-to-skin contact 2. Alternative Feeding Methods for Breastfed Babies [Policy: 270CWH-NB-15]

• Protocol for alternative feeding methods (such as cup feeding, finger feeding, supplemental feeding system, syringe or eye dropper

feeding, and spoon feeding), and formula supplementation 3. Breastfeeding Care of the Well Newborn

• Protocol for health professionals assisting breastfeeding mothers and infants with the initiation of breastfeeding, assessment of

positioning, assessment of latch, and preparation for discharge

4. Breastfeeding: Protection, Promotion and Support for Healthy Term Infants [Policy:

PRC-011]

• Protocol related to Steps 3-10 of the BFI

Although Eastern Health’s infant feeding policies encourage, promote, and support exclusive breastfeeding, when compared to BFI Integrated Ten Steps, policy gaps are evident. While Eastern Health’s policies emphasize a clear commitment to BFI practice standards through policies detailing breastfeeding positioning and assistance, skin-to-skin contact, informed decision-making, and the use of alternative feeding methods in support of exclusive breastfeeding, they do not thoroughly address all components of Steps 3-10 of the BFI.

It should be noted that policies in this review were developed for the care of well newborns without specialized care or feeding needs. Infant feeding policies and protocols for un-well newborns were beyond the scope of this research.

Although written to promote and support exclusive breastfeeding, and to adhere to policies and protocols outlined in the BFI, this review indicates that Eastern Health infant feeding policies fall short of incorporating all policy standards for each of the BFI Integrated Ten Steps. See

Appendix A for details on each policy.

(23)

Summary of Results

An examination of maternal healthcare experiences and infant feeding policy guidelines at the Janeway Children’s Hospital/Health Sciences Centre reveals discrepancies between BFI practice guidelines and hospital infant feeding healthcare practices. Maternal accounts indicate a lack of full adherence with the guidelines specified for Steps 3-9 of the BFI (and possible adherence with Step 10).

Maternal accounts highlight a need for routine communication between healthcare providers and mothers in hospital on: the importance and process of breastfeeding (Step 3), the implications of supplementation (Step 6), how to initiate and maintain lactation if separated (Step 5), how to pump and store breastmilk (Step 5), and how to recognize infant feeding cues (Step 5), and signs of effective feeding (Step 5). Maternal reports also highlight a need for longer durations of skin- to-skin contact (Step 4), the provision of breastfeeding assistance at subsequent intervals (Step 5), and the provision of rooming-in the first night in hospital (Step 7).

Hospital healthcare practices could also be improved by ensuring all mother-infant dyads remain together for infant exams (Step 7), are able to have a support person stay with them overnight in hospital (Step 7), are encouraged to feed according to infant feeding cues (Step 8), and are informed of how to feed without the use of an artificial nipple attachment (Step 9). Maternal accounts suggest possible adherence to Step 10, however indicate that current hospital infant feeding practices do not adhere to evidence-informed guidelines outlined in the BFI Integrated Ten Steps.

Mothers suggested that breastfeeding is an emotionally and physically demanding practice that is idealized and expected of them, while also not always culturally accepted in the public sphere in NL. This reinforces the importance of community supports for mothers, and interventions focused on changing cultural attitudes towards breastfeeding in the public sphere.⁸

A review of Eastern Health infant feeding policies highlight a commitment to BFI practice standards, but numerous gaps must be filled in order to align these policies with each step and sub-step of the BFI.

Inconsistencies in care provision were commonly reported, indicating a potential need for improved breastfeeding education, training, and supportive working conditions for nurses; and improved policy communication, monitoring, and alignment with BFI guidelines.

8 For more information on maternal expereince with the practice and culture of breastfeeding, please see Chapter 5 of: Fullerton, L.M. (2014). THESIS: Infant feeding and institutional compliance with the WHO/UNICEF Baby- Friendly Initiative – An assessment through maternal experience. Memorial University.

(24)

Key Recommendations

1. Update existing policies: Update Eastern Health infant feeding policies for healthy newborns to align with all Steps and Sub-Steps of the BFI Ten Steps to Successful Breastfeeding.

2. Prioritize regular policy communication among allied health professionals: Ensure health professionals working with mothers in pregnancy, labour/delivery, and post- partum recovery are knowledgeable of hospital policies about breastfeeding.

3. Provide regular and mandatory BFI training for health professionals: Ensure all health professionals providing care to mothers in pregnancy, labour/delivery, and the early post-partum period have completed BFI training, and have the knowledge and skills needed to confidently support the success of mother/infant dyads with breastfeeding.

4. Provide allied health professionals with the organizational and supportive work conditions necessary to implement BFI practice guidelines: Ensure all health professionals working with mothers in pregnancy, labour/delivery, and the early post- partum period are supported (through, for example, appropriate scheduling, patient loads, length of shifts, access to resources) to provide mothers with high-quality and consistent infant feeding information, assistance, and support.

5. Enhance communication between mothers and allied health professionals: Ensure every mother has a chance prior to discharge to talk with a BFI-trained health

professional about the importance and process of breastfeeding, and implications of supplementation, as well as how to recognize infant feeding cues, and signs of effective feeding. Ensure mothers are provided with regular opportunities during their hospital stay to talk with health care providers and ask questions.

6. Prioritize skin-to-skin contact for one full hour or as long as the mother wishes:

Ensure skin-to-skin contact immediately after birth for the duration of one hour or as long as the mother wishes.

7. Encourage overnight rooming-in the first night in hospital for all mother-infant dyads: Ensure mothers and infants remain together in the same room overnight. Do not separate mother/infant dyads overnight unless required for medical reasons.

8. Encourage cue-based feeding rather than feeding at timed intervals: Encourage mothers to feed on demand by recognizing and responding to infant feeding cues. Ensure mothers are aware of signs of effective feeding.

9. Provide mothers with access to a certified lactation consultant in hospital: Ensure a certified lactation consultant is available to assist mothers with breastfeeding in hospital 7 days a week.

(25)

Conclusion

Breastfeeding is promoted globally through the WHO/UNICEF Baby-Friendly Initiative because it reduces infant mortality and morbidity, protects against infections and chronic conditions, promotes optimal infant growth and development, and enhances maternal health. While there are currently no accredited BFI healthcare institutions in the province of NL, meeting BFI practice guidelines is a healthcare goal supported by the Government of NL, NL Provincial Perinatal Program, Baby-Friendly Council of NL, and all four Regional Health Authorities.

Although breastmilk is optimal for infant health and development for a number of reasons, breastfeeding may not always be possible or optimal for every mother or mother-infant dyad. For this reason, it is of critical importance to ensure that mothers are supported with dignity and respect to make informed decisions about their infant feeding practice. While the BFI

emphasizes informed decision-making and the provision of support for supplementing mothers, it is important this is upheld in healthcare settings.

Healthcare practices play a critical role in facilitating early and ongoing success with

breastfeeding. In the province of NL, there are clear opportunities to improve hospital healthcare practices to promote exclusive breastfeeding and support mother/infant dyads to establish early and ongoing success with this beneficial practice.

(26)

References

Breastfeeding Committee for Canada. (2012a). BFI integrated 10 steps practice outcome indicators for hospitals and community health services. Retrieved from

http://breastfeedingcanada.ca/documents/2012-

0514_BCC_BFI_Ten_Steps_Integrated_Indicators.pdf

Breastfeeding Committee for Canada. (2012b). BFI integrated 10 steps practice outcome indicators for hospitals and community health services: Summary. Retrieved from:

http://breastfeedingcanada.ca/documents/2012-05-

14_BCC_BFI_Ten_Steps_Integrated_Indicators_Summary.pdf

Bursey, C. (2012). Skin-to-skin contact immediately following birth. Policy 270 (WH) II-D-83. Women and Children’s Health Program. Eastern Health, St. John’s, NL.

Bursey, C. & Goobey, O. (2012). Alternative feeding methods for breastfed babies. Policy 270CWH-NB- 15. Women and Children’s Health Program. Eastern Health, St. John’s, NL

Chalmers, B., Levitt, C., Heaman, M., O’Brien, B., Suave, R., Kaczorowski, J. (2009). Breastfeeding rates and hospital breastfeeding practices in Canada: A national survey. Birth, 36(2), 122-132.

doi:10.1111/j.1523-536X.2009.00309.x

Crocker, D. (2012). Breastfeeding: Protection, promotion and support for healthy term infants. Policy PRC-011. Women and Children’s Health Program. Eastern Health, St. John’s, NL.

Ip, S. Cheung, M., Raman, G., Chew, P., Magula, N., DeVine, D., … Lau, J. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. In: Evidence Report/Technology Assessment Number 153. Agency for Healthcare Research and Quality.

Newfoundland and Labrador Provincial Perinatal Program. (2006). Neonatal Breastfeeding Statistics 1986-2005. [Joint position paper]. Data retrieved:

http://www.cpha.ca/uploads/provinces/nlbreastfeedingpaper.pdf

Newfoundland and Labrador Provincial Perinatal Program. (2013). Provincial Neonatal Screening Program. Eastern Health, St. John’s, NL.

Public Health Agency of Canada. (2009). What mother’s say: The Canadian maternity experiences survey. Ottawa: Public Health Agency of Canada. Retrieved from: http://www.phac- aspc.gc.ca/rhs-ssg/survey-eng.php

Women and Children’s Health Program. (2012). Breastfeeding care of the well newborn [Draft policy].

Eastern Health, St. John’s, NL. Retrieved on March 28^,2012.

World Health Organization. (2006). The International Code of Marketing of Breast Milk Substitutes – Frequently asked questions. Geneva: WHO Press. Retrieved from

http://www.who.int/maternal_child_adolescent/documents/9241594292/en/

World Health Organization. (2007). Evidence on the long-term effects of breastfeeding. Geneva: WHO Press. Retrieved from:

http://www.who.int/maternal_child_adolescent/documents/9241595230/en/

(27)

UNIECF/World Health Organization. (2009). Baby-Friendly Hospital Initiative: Revised, updated and expanded for integrated care. Section 1: Background and Implementation. Geneva: WHO Press.

http://www.unicef.org/nutrition/files/BFHI_2009_s1.pdf

World Health Organization/UNICEF. (1989). Protecting, promoting, and supporting breast-feeding: The special role of maternity services. A joint WHO/UNICEF statement. Geneva: WHO Press.

Retrieved from: http://www.who.int/nutrition/publications/infantfeeding/9241561300/en/

Infant Feeding and Institutional Adherence with the Baby-Friendly Initiative: An Assessment through Maternal Experience and Review of Policy and Protocol